Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy (CBT) developed in the 1980s to help patients with severe mental health disorders when standard CBT was ineffective. The founder of DBT, Dr. Marsha Linehan, established the Linehan Institute in 1997, now known as the Behavioral Tech Institute. To explore research and various articles related to the initial formation and current best practices for DBT, please visit the Behavioral Tech Knowledge Center.
DBT: A Quick History
Dr. Linehan developed DBT for a specific purpose: to support women with severe borderline personality disorder (BPD). In her clinical work with patients, she observed that the traditional approaches used in cognitive behavioral therapy (CBT) had little impact on managing the most disruptive and challenging symptoms. To help the women in her care manage their emotions and tolerate their extremes, she altered elements of CBT and found that her adjustments and new approach – which she later called dialectical behavior therapy (DBT) – were effective in decreasing the frequency and severity of behaviors such as non-suicidal self-injury (NSSI) and suicidal ideation (SI).
What Type of Patients Do Best With DBT?
Studies conducted over the past twenty years on DBT shows its most effective for people with mental health disorders characterized by symptoms involving high emotional reactivity and extreme/out-of-control/hard to manage patterns of thought, behavior, and emotion. To read on of Dr. Linehan’s initial article on DBT, click here. For an update on how DBT has changed since its initial creation, read this article on DBT, also by Dr. Linehan. To dive all the way into DBT, you can read the latest edition of the standard DBT textbook, Dialectical Behavior Therapy in Clinical Practice: Second Edition.
The research in the articles and books above shows how DBT can help people who experience:
- Suicidal ideation (SI) or non-suicidal self-injury (NSSI)
- Major depression (MDD)
- Posttraumatic stress disorder (PTSD)
- Borderline personality disorder (BPD)
- Bipolar disorder (BD)
- Emotional dysregulation
- Behavioral dysregulation
- Childhood or early trauma, i.e. adverse childhood experiences (ACEs)
The development of DBT was an important step in the evolution of psychotherapy. Previously, many therapists would either not accept patients with the most extreme and volatile emotional symptoms, or refer them to immersive, inpatient hospitalization programs, where they may or may not have received the type of targeted treatment they needed.
How Does DBT Work?
According to the Behavioral Tech Institute, DBT has three primary modes of delivery in the context of outpatient treatment, which is the context in which DBT at BACA takes place. These primary DBT modes include:
Individual Talk Therapy
- Structured DBT Sessions typically occur once a week – or as determined through collaboration between patient and therapist – in conjunction with DBT skills training.
DBT Skills Training
DBT skills include:
- Mindfulness
- Distress Tolerance
- Interpersonal Effectiveness
- Emotion Regulation
One-on-One Coaching
- Most DBT therapists use the telephone to offer support and coaching in-the-moment, i.e. when their patient experiences a stressful or distressing situation or set of circumstances and needs help applying DBT skills. Between sessions, patients can call DBT therapists to receive specific, moment-to-moment coaching when they need it most.
DBT therapists apply these modalities with a perspective commonly referred to as a skills deficit model. This is the underlying assumption behind DBT: patients with various mental health disorders show deficits in emotional regulation skills, which can in turn lead to the use of maladaptive behaviors or patterns of behavior to regulate challenging emotions and manage or tolerate distress. These maladaptive patterns result in symptoms we often observe from the outside: withdrawal from friends and family, emotional volatility, unstable relationships, alcohol or drug use, an inability to meet the basic demands of daily life, and other disruptive symptoms, up to and including suicidality/suicidal behavior.
Here’s how the DBT skills help patients:
Mindfulness
This module teaches patients practical, useful mindfulness techniques to gain valuable insight into their habitual patterns of emotion and thought. The insight patients develop practicing mindfulness helps them manage emotions and thoughts that are disruptive. The core skill of mindfulness is the ability to recognize and identify emotions and thoughts without judgment and without defaulting to habitual patterns. For example, when we experience an emotion, we most often label it as good or bad, positive or negative, or something in between.
Those labels carry value judgments mindfulness can interrupt and counteract. Mindfulness teaches us to allow emotions to simply be there without labeling them with one quality or another: they simply are what they are. Once we learn to identify our emotions without labeling them, a DBT therapist can help us change our behavioral response to that emotion – which can have a significant, positive impact almost immediately.
Emotion Regulation
The skills learned in the mindfulness module support emotional regulation. This module helps develop the skills necessary to manage extremes of feeling and emotion. A person with a mental health disorder characterized by high emotional reactivity experiences emotions that are so intense and disruptive it’s hard for people without emotional challenges to understand: they don’t want their emotions to be that intense, but they are. A person who works with a therapist on DBT skills can learn to prevent their emotions from taking over and dominating their lives. The skills patients can learn thought DBT are empowering. For many patients, applying DBT skills allows them to manage their emotions in a healthy, productive manner for the first time in years.
Interpersonal Effectiveness
This component of DBT is about learning how to manage and maintain healthy relationships. Technically speaking, interpersonal effectiveness means the ability to get what you want and need from your relationships.
Patients can apply mindfulness and emotion regulation skills to relationships not only with family, friends, and peers, but also with other people in their lives, such as coworkers and teachers. Skills from this module include the ability to identify personal needs, understand/describe them in the moment, communicate them to other people, and set appropriate boundaries, including learning when it’s appropriate to say yes or no. Patients often use the skills they learn in this DBT module to restore balance to important relationships that may have been negatively impacted by behavior associated with the symptoms of a severe mental health disorder.
Distress Tolerance
No matter how much we try to avoid them, stressful things happen. Everyone finds themselves in difficult situations, and at times most of us also experience what we call crisis. Physical, emotional, or psychological crisis, it’s likely that at some point during our lives, we’ll find ourselves in a situation we simply can’t handle. The distress tolerance module of DBT is designed to help people with mental behavioral, or emotional challenges successfully manage – and survive – a mental health crisis.
However, the skills need to be in place before the crisis for them to be effective. That’s why DBT therapists spend a significant amount of time teaching patients a set of practical skills they can use in any moment. Our emotions can cause us to behave in impulsive and counterproductive ways that exacerbate, rather than de-escalate, challenging situations such as a mental, psychological, or emotional crisis. Distress tolerance skills help patients navigate moments of distress, challenge, and crisis from a place of calm and inner peace, rather than a place characterized by reactivity and impulsivity. Developing effective distress tolerance skills takes time and commitment, but the effort is worth it. With DBT, a patient in crisis can make positive, healthy choices that support and promote overall mental health and wellbeing.
Benefits of DBT
In working through the DBT modules, patients learn more about themselves and how to better handle troubling situations overall. Depending on their diagnosis and severity of symptoms, DBT can be vastly more helpful than talk therapy alone. The step-wise, organized system, the worksheets, and the practical skills practice all combine to help people with mental health disorders characterized by a high level of emotional reactivity and an underdeveloped set of coping skills to manage or tolerate stressful situations and circumstances,
For some of us, regulating emotions and tolerating stress are skills we develop as we grow and mature. They feel like second nature, even if some of the lessons were hard to learn. We may have learned the skills from parents, siblings, teachers, coaches, or mentors, or we may have figure them out ourselves over a lifetime of trial and error.
However, there are many people who were not fortunate enough to learn how to regulate their own emotions and feelings, and have an extremely hard time managing stress, especially stress related to feelings, emotions, and relationships.
DBT can be life-changing for those patients.
Each session can give patients skills that they can use for their rest of their lives. While treatment doesn’t have to end after completing the DBT modules, completing them can give the patients a sense of accomplishment. They know they completed something both challenging and good for them, and along the way, learned new ways to handle their psychological, emotional – and often social/relational – challenges and problems.
A Recap: DBT Compared to Standard Psychotherapy
The title of this article asks a question that I hope I answered clearly, above. I’ll reiterate the important parts – your takeaways – so we’re on the same page.
DBT vs. Standard Talk Therapy
- DBT is different from talk therapy in that during DBT sessions, a DBT therapist works through specific modules with each patient.
- With talk therapy, there is not as much structure as with DBT. In talk therapy sessions, the patient might just need someone to bounce ideas off of in a non-judgmental and safe setting.
- The therapist in this case can offer advice or guidance. They can even assist with challenging the patient’s negative thoughts or helping reframe a situation in a more positive way.
- However, compared to DBT, there is no concrete curriculum for treatment sessions. The content and topic of each therapy session can be – and often is – guided by the patient, rather than a predetermined skill-building sequence, like the one built into the DBT process.
It’s important to understand the difference between DBT and standard talk therapy in context. For people with mental health or behavioral disorders with symptoms that aren’t extremely severe and disruptive, and more importantly, are not characterized by volatility with a risk of harm, standard talk psychotherapy can work wonders, lead to symptom relief, and help patients rediscover balance in their lives.
However, for people with disorders/diagnoses characterized by high levels of reactivity, impulsivity, and volatility, typical talk psychotherapy might not help at all, whereas the core skills of DBT can help them manage those strong emotions without being at their mercy. A patient with a complex mental health diagnosis who spends time working with a skilled DBT therapist can make real progress, gain agency, and learn to process and manage their emotions in positive, healthy, and productive ways. Standard psychotherapy can do that for most patients, but in some cases, DBT is literally exactly what the doctor ordered.
